A ppt which discusses breast cancer cases and the treatment modality followed based on the diagnostic workup

1. CASE STUDY OF BREAST CANCER PATIENTS AND
RELEVANCE OF TARGETED THERAPY
By: Shreya S
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2. TABLE OF CONTENTS
 OBJECTIVES
 INTRODUCTION
 LITERATURE REVIEW
 MATERIALS & METHODS
 RESULTS
 CONCLUSION
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3. OBJECTIVES
 To provide systematic analysis of a breast cancer case for
generation of treatment plan.
 To understand the relevance of targeted therapy in
treatment of breast cancer.
 To study the NCCN guidelines for treatment of breast
cancer.
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4. Cancer & It’s Symptoms
 Uncontrolled growth of cells
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5. Cancer Grade
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6. LITERATURE REVIEW
 Treatment Stratergies :
 Waks & Winer 2019 –
 Breast Conservative Surgery (lumpectomy) – small tumor, no nodal involvement
 siewicz, Czeczelewski, Forma, Baj, Sitarz&Stanisławek 2021 –
 Mastectomy
 Gherghe, Bordea& Blidaru 2015; Guo, Jiajia Yang, Houpu 2017; Frumovitz, M. et
al. 2018
 Lymph node dissection
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7.  Brown, Mutter & Halyard 2015
 External Beam Radiation Therapy – whole breast/chest wall (40-
60Gy); external photon beam target
 Stewart, Khan & Devlin 2010
 Intensity Modified Radiation Therapy – several beam angles are used
 Esposito, Anninga, Harris, Capasso, D’Aiuto, Rinaldo & Douek 2015
 Intra-operative Radiation Therapy
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8.  Rutqvist, Rose &Cavallin-Ståhl 2009
 Image-guided radiation therapy (IGRT)  better precision
and accuracy of treatment
 Skowronek & Chicheł 2014
 Brachytherapy: internal radiation; implants placed; under
anasthesia
 Systemic Therapy : chemo/endocrine/targeted therapy
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9. MATERIALS & METHODS
Comprehensive workflow of the case study
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10. Step 1 – Registration of patients:
 Patients  any cancer of organ, stage, economic status/background,
geographical location, patient themselves or the caregivers  registration
 Information Required:
 Patient name, Gender, DOB, Address, Phone number
 Cancer of organ
 Patient’s family history of cancer, social history, menopausal status of the
patient
 Past medical and surgical history of the patient
 Patient’s questions to the experts
 User’s personal details – name, address, phone number
 Medical Reports  Pathology/Radiology/Treatment/NGS/Provider Notes
etc.
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11. Step 2 - Selection of cancer of organ
 As patients with any cancer of organ can register on the website; with
regards to the case study only one cancer of organ was selected
 The cancer of organ selected for this case study is breast cancers, for the
following reasons:
 High prevalence of breast cancer compared to other cancer
 Well studied form of cancer and still lots of ongoing research for possible
innovative treatment options for the patients
 Availability of detailed diagnostic plan
 An array of possible treatment strategies available
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12. Step 3 - Selection of breast cancer case
 After the breast cancer case was selected, the following steps
were performed individually on the case:
 Analysis of diagnostic workup
 Staging of cancer
 Analysis of treatment plan followed
 Structured case summary sent to Experts
 Expert opinion
 Identification of any deviation of treatment if any.
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13. CASE STUDY
69 years old female with locally advanced ER +ve/ PR –ve and
HER2neu +ve breast cancer, invasive ductal carcinoma with
involvement of infraclavicular, supraclavicular, axillary lymph nodes.
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14. Complete Flow of Case
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15.  Current Diagnosis: Locally advanced breast cancer
 Age: 69 Years Old
 Gender: Female
 Menopausal Status: Postmenopausal
 PMH: Diabetes - DM Type 2 & Hypertension (High BP)
 Family history of cancer: No family history of cancer
 Social history: Occasional consumption of alcohol.
 Complaint(s): Right breast Lump [June 2020]
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16. 16
SL.
NO TESTS PERFORMED DATE FINDINGS/IMPRESSION
1. Bilateral Breast MRI [August 11th, 2020]
5.6*4.5*4.2 cm 2 to 4 o'clock position right breast lesion
with adjacent satellite lesion and ductal enhancement
additional invasion of overlying skin and nipple
involvement.
2. Core Biopsy - Right Breast [August 11th, 2020] IDC, Grade
III ER – Status: Low Positive PR – Status:
Negative HER 2 NEU Receptors – Status:
Positive.
3. FDG-PET CT Whole body
[September 3rd, 2020] 3.3*2.7 cm right breast 3 o'clock position lesion (SUV
17.5) with adjacent satellite nodules with extension to
skin surface. Ipsilateral infraclavicular, internal
mammary, axillary, supraclavicular lymphadenopathy.
No e/o
malignancy elsewhere.
4. Biopsy- Infraclavicular LN
[September 1st, 2020] Metastatic
Carcinoma
IHC-Positive – GATA3, CK7
IHC-Negative – CK20

17. 17
Treatment/Regimen/Surgery performed Duration (start date to end
date)
Comments
1) Docetaxel (100) + Pertuzumab (420) + Trastuzumab (6)
every 21 days.
September 2020 – January
2021
Six cycles completed.
Response Assessment scans performed – B/l breast MRI imaging and CT CAP – in January 2021
– showed concordant findings stating reduction in size of right breast lesion with resolution of adenopathy i.e., with no metastasis in body
demonstrating partial response to the treatment.
2) Right Modified Radical Mastectomy + Sentinel Lymph Node
Dissection
February 2021 Pathological assessment performed on the
specimens collected.
Surgical pathological report showed
- Grade 3 IDC, MRBS 9
- Out of 4 resected SLN, none were positive for malignancy
- Absence of DCIS and LCIS
- No LVI was observed
- No pathological skin and skeletal involvements
3) Pertuzumab + Trastuzumab every 21 days. Started in February 2021 and
ongoing
Details about the dose, cycles completed not
available.
4) External Beam Radiation Therapy - 3D X – Ray Radiation
Therapy – 45 Gy in twenty-five fractions to chest wall.
April 2021 – May 2021 Completed Radiation therapy.

18. • General Condition and Performance status of the
patient: Patient can do activities of daily living without
assistance; no significant disease related symptoms.
ECOG: 0-1
• Patients Question to the experts :
What is recommended at this time: hormone therapy or
targeted therapy or an alternate treatment?
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19. RESULTS AND DISCUSSION
 Minimum Diagnostic Work up – Breast
 MRI
 US
 Mammogram
 Biopsy
 FDG PET CT scan
 IHC for ER/PR/HER2neu status of cancer cells.
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20. NCCN Guidelines – Diagnostic work up
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21.  Primary organ imaging scan performed : bilateral a breast MRI 
provides detailed description of the lesion due to the multi-planarity
of the MRI scans  for the diagnosis of breast cancer
 Core biopsy  confirmation of malignancy by providing the histology,
cancer grade, receptor status of cancer.
 whole- body PET CT  metastatic workup  showed no distant organ
metastasis.
 Infraclavicular LN biopsy  extent of the spread of cancer
 Involvement of the regional LN => Stage III locally advanced breast
cancer.
 Stage Receptor status => minimum diagnostic workup complete.
 Treatment can be started
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22. NCCN compliance of treatment followed
before acquisition of expert opinion.
 Primary treatment modality for breast cancer  Surgery
=> maximum cure rates.
 Surgery performed - Modified Radical Mastectomy +
Sentinel lymph node dissection.
 MRM surgery provides the maximal cure rates when there
are no other involvements of the tumor and there is
absence of distant metastasis.
 several regional lymph nodes involvements and invasions
 better local control of the disease  neo-adjuvant
chemotherapy + targeted therapy with docetaxel and
pertuzumab with trastuzumab.
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23.  NCCN Guidelines suggests preoperative systemic therapy
in cases of N3 nodal disease, bulky or matted N2 axillary
nodes, T4 tumors, N+ disease likely to become cN0 with
preoperative systemic therapy.
 After concurrent NACT + NA targeted therapy, surgery was
performed taking into consideration the rescinding disease
as response to the treatment evident from the response
assessment scans done.
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24.  According to NCCN Guidelines, in cases where
preoperative or adjuvant systemic therapy is given, RT is
suggested to be targeted to the ipsilateral chest wall,
mastectomy scar and drain sites. RT dose is 40- 45Gy in
25-28 fractions to the chest wall. Pt had ongoing adjuvant
targeted therapy with only trastuzumab and pertuzumab.
 Hence, overall, the treatment followed by the patient as
suggested by her treating oncologist was NCCN compliant.
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25. NCCN Compliance of Expert Opinion
 Anastrozole 1 mg once daily + Trastuzumab 2mg/kg every week
with a loading dose of 4 mg/kg on day one of the first cycle for
4-6 cycles
 Letrozole 1 mg once daily + Trastuzumab 2mg/kg every week
with a loading dose of 4 mg/kg on day one of the first cycle for
4-6 cycles
 Assessment of response with CT scans of the
chest/abdomen/pelvis with oral and iv contrast or PET CT scan
of the whole body
 The ongoing therapy followed by the patient is only targeted
therapy, but expert opinion is to add endocrine therapy to the
ongoing regimen for better efficiency and remission of cancer.
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26. 26

27. Expert opinion is NCCN compliant. Hence, the treatment
being followed by the patient can be rectified by the Expert
opinion.
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28. Relevance of Targeted Therapy
 HR +ve breast cancer prevention: Endocrine therapy gold
standard
 SERM’s : tamoxifen, aromatase inhibitors like anastrozole,
letrozole, and exemestane
 SERD’s : fulvestrant
 CDK 4/6 inhibitors, mTOR/PIK3 inhibitors, and histone
deacetylase inhibitors + anti-estrogen therapy
 EGFR 2 status
 HER2 + => Trastuzumab
 Trastuzumab + Pertuzumab
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29.  TNBC Cases:
 BRCA1/2 mutations => worst prognosis
 PARP Inhibitors
 Programmed death-1 (PD-1) inhibitors
 programmed death-ligand 1 (PD-L1) inhibitors
 cytotoxic T-lymphocyte-associated antigen-4 (CTLA-4)
inhibitors
 Anti-VEGF agent
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30. CONCLUSION
 Historically, treatment  castration
 Increasing knowledge : pathogenesis, pathophysiology,
biomolecular overexpression of certain targetable
proteins, interconnecting pathways, genetic factors
 Progress in the targeted therapies and novel treatment
approaches => Mortality rate decreased
 Molecular and biochemical abnormalities => personalized
targeted therapy
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31.  NCCN => clinicians make better-informed decision
 Deviations from NCCN => newer advances
 Benefit over weighs the risk
 Primary Goal:
 Cure, survival, improvement in symptoms and quality of
life.
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32. REFERENCES
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safety of external beam radiation therapy for breast cancer’,
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 Stewart, A. J., Khan, A. J. and Devlin, P. M. (2010) ‘Partial breast
irradiation: a review of techniques and indications’, The British Journal of
Radiology, 83(989), p. 369. doi: 10.1259/BJR/11505970.
 Esposito, E. et al. (2015) ‘Intraoperative radiotherapy in early breast
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 tqvist, L. E., Rose, C. and Cavallin-Ståhl, E. (2009) ‘A Systematic
Overview of Radiation Therapy Effects in Breast Cancer’,
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33.  Skowronek, J. and Chicheł, A. (2014) ‘Brachytherapy in breast cancer: an
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 GAndrahennadi, S. et al. (2021) ‘Current Landscape of Targeted Therapy in
Hormone Receptor- Positive and HER2-Negative Breast Cancer’, Current
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10.3390/CURRONCOL28030168.
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molecular features and progression pathways’, Histopathology, 57(2), pp. 171–
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34.  X.Ju, J., Zhu, A.-J. and Yuan, P. (2018) ‘Progress in targeted
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35.  uo, J. et al. (2017) ‘Comparison of sentinel lymph node
biopsy guided by indocyanine green, blue dye, and their
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(Accessed: 16 April 2022).
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36. Thank You!
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